Chukwuemeka Onwuchekwa · Laura Mora Moreo · Sonia Menon · Belen Machado · Daniel Curcio · Warren Kalina · Jessica E Atwell · Bradford D Gessner · MARIANA SIAPKA · Neha Agarwal · Michelle Rubbrecht · Harish Nair · Mark Rozenbaum · Zuleika Aponte-Torres · Hilde Vroling · Elizabeth Begier

The Journal of Infectious Diseases, 2023, jiad012

Abstract

Background

Most observational population-based studies identify RSV by nasal/nasopharyngeal swab RT-PCR only. We conducted a systematic review and meta-analyses to quantify specimen and diagnostic testing-based under-ascertainment of adult RSV infection.

Methods

EMBASE, PubMed and Web of Science were searched (Jan2000-Dec2021) for studies including adults using/comparing >1 RSV testing approach. We quantified test performance and RSV detection increase associated with using multiple specimen types.

Results

Among 8066 references identified, 154 met inclusion. Compared to RT-PCR, other methods were less sensitive: rapid antigen detection (pooled sensitivity, 64%), direct fluorescent antibody (83%), and viral culture (86%). Compared to singleplex PCR, multiplex PCR’s sensitivity was lower (93%). Compared to nasal/nasopharyngeal swab RT-PCR alone, adding another specimen type increased detection: sputum RT-PCR, 52%; 4-fold rise in paired serology, 44%; and oropharyngeal swab RT-PCR, 28%. Sensitivity was lower in estimates limited to only adults (for RADT, DFA and Viral culture), and detection rate increases were largely comparable.

Conclusions

RT-PCR, particularly singleplex testing, is the most sensitive RSV diagnostic test in adults. Adding additional specimen types to nasopharyngeal swab RT-PCR testing increased RSV detection. Synergistic effects of using ≥3 specimen types should be assessed, as this approach may improve the accuracy of adult RSV burden estimates.

Hillary Koros · Ellen Nolte · Jemima H Kamano · Richard Mugo · Adrianna Murphy · Violet Naanyu · Ruth Willis · TRIANTAFYLLOS PLIAKAS · David T Eton · Edwina Barasa · Pablo Perel

PLOS Global Public Health, 2023, 3(1): e0001407

Abstract

In Kenya, non-communicable diseases (NCDs) are an increasingly important cause of morbidity and mortality, requiring both better access to health care services and self-care support. Evidence suggests that treatment burdens can negatively affect adherence to treatment and quality of life. In this study, we explored the treatment and self-management burden among people with NCDs in in two counties in Western Kenya. We conducted a cross-sectional survey of people newly diagnosed with diabetes and/or hypertension, using the Patient Experience with Treatment and Self-Management (PETS) instrument. A total of 301 people with diabetes and/or hypertension completed the survey (63% female, mean age = 57 years). They reported the highest treatment burdens in the domains of medical and health care expenses, monitoring health, exhaustion related to self-management, diet and exercise/physical therapy. Treatment burden scores differed by county, age, gender, education, income and number of chronic conditions. Younger respondents (<60 years) reported higher burden for medication side effects (p<0.05), diet (p<0.05), and medical appointments (p = 0.075). Those with no formal education or low income also reported higher burden for diet and for medical expenses. People with health insurance cover reported lower (albeit still comparatively high) burden for medical expenses compared to those without it. Our findings provide important insights for Kenya and similar settings where governments are working to achieve universal health coverage by highlighting the importance of financial protection not only to prevent the economic burden of seeking health care for chronic conditions but also to reduce the associated treatment burden.

Greg Hartwell · Matt Egan · Jamie Brown · TRIANTAFYLLOS PLIAKAS · Mark Petticrew

Toxics, 2022, 10(10):593

Abstract

Little is known about whether e-cigarette use influences tobacco smokers’ decisions around other smoking cessation options, including the most effective one available: stop smoking service (SSS) attendance. Our repeat cross-sectional survey therefore assessed associations between use of e-cigarettes with past and planned future uptake of SSSs. Nicotine replacement therapy (NRT) use was also assessed as a comparator. Participants were drawn from the Smoking Toolkit Study, a nationally representative, validated, face-to-face survey. Data were aggregated on 2139 English adults reporting current smoking of cigarettes or other tobacco products. Multivariable logistic regression was used to adjust for potential confounders. Results showed dual users of combustible tobacco and e-cigarettes were more likely than other smokers to report having accessed SSSs in the past (AOR 1.43, 95% CI 1.08 to 1.90) and intending to take up these services in future (AOR 1.51, 95% CI 1.14 to 2.00). Dual users of combustible tobacco and NRT showed similar associations. Secondary objectives provided evidence on key psychosocial factors that influenced smokers’ decision-making in this area. In summary, despite speculation that e-cigarette use might deter smokers from accessing SSSs, our study found dual users of tobacco and e-cigarettes were more likely to report uptake of such services, compared to smokers not using e-cigarettes.

Matthew Quaife · Graham F Medley · Mark Jit · Tom Drake · Miqdad Asaria · Pieter van Baal · Rob Baltussen · Lori Bollinger · Fiammetta Bozzani · Oliver Brady · Henk Broekhuizen · Kalipso Chalkidou · Y-Ling Chi · David W Dowdy · Susan Griffin · Hassan Haghparast-Bidgoli · Timothy Hallett · Katharina Hauck · Deirdre T Hollingsworth · Finn C McQuaid · Nicolas A Menzies · Maria W Merritt · Andrew Mirelman · Alec Morton · Francis J Ruiz · MARIANA SIAPKA · Jolene Skordis · Fabrizio Tediosi · Patrick Walker · Richard G White · Peter Winskill · Anna Vassall · Gabriela B Gomez

Epidemics, 2022, 41:100648

Abstract

Objectives

Disease transmission models are used in impact assessment and economic evaluations of infectious disease prevention and treatment strategies, prominently so in the COVID-19 response. These models rarely consider dimensions of equity relating to the differential health burden between individuals and groups. We describe concepts and approaches which are useful when considering equity in the priority setting process, and outline the technical choices concerning model structure, outputs, and data requirements needed to use transmission models in analyses of health equity.

Methods

We reviewed the literature on equity concepts and approaches to their application in economic evaluation and undertook a technical consultation on how equity can be incorporated in priority setting for infectious disease control. The technical consultation brought together health economists with an interest in equity-informative economic evaluation, ethicists specialising in public health, mathematical modellers from various disease backgrounds, and representatives of global health funding and technical assistance organisations, to formulate key areas of consensus and recommendations.

Results

We provide a series of recommendations for applying the Reference Case for Economic Evaluation in Global Health to infectious disease interventions, comprising guidance on 1) the specification of equity concepts; 2) choice of evaluation framework; 3) model structure; and 4) data needs. We present available conceptual and analytical choices, for example how correlation between different equity- and disease-relevant strata should be considered dependent on available data, and outline how assumptions and data limitations can be reported transparently by noting key factors for consideration.

Conclusions

Current developments in economic evaluations in global health provide a wide range of methodologies to incorporate equity into economic evaluations. Those employing infectious disease models need to use these frameworks more in priority setting to accurately represent health inequities. We provide guidance on the technical approaches to support this goal and ultimately, to achieve more equitable health policies.

James R Hargreaves · TRIANTAFYLLOS PLIAKAS · Graeme Hoddinott · Tila Mainga · Constance Mubekapi-Musadaidzwa · Deborah Donnell · Ethan Wilson · Estelle Piwowar-Manning · Yaw Agyei · Nomtha F Bell-Mandla · Rory Dunbar · Ab Schaap · David Macleod · Sian Floyd · Peter Bock · Sarah Fidler · Janet Seeley · Anne Stangl · Virginia Bond · Helen Ayles · Richard Hayes · HPTN 071 (PopART) study team

Journal of the International AIDS Society, 2022, 25(Suppl 1): e25931

Abstract

Introduction

To investigate the association between individual and community‐level measures of HIV stigma and HIV incidence within the 21 communities participating in the HPTN (071) PopART trial in Zambia and South Africa.

Methods

Secondary analysis of data from a population‐based cohort followed‐up over 36 months between 2013 and 2018. The outcome was rate of incident HIV infection among individuals who were HIV negative at cohort entry. Individual‐level exposures, measured in a random sample of all participants, were: (1) perception of stigma in the community, (2) perception of stigma in health settings and (3) fear and judgement towards people living with HIV. Individual‐level analyses were conducted with adjusted, individual‐level Poisson regression. Community‐level HIV stigma exposures drew on data reported by people living with HIV, health workers and community members. We used linear regression to explore the association between HIV stigma and community‐level HIV incidence.

Results

Among 8172 individuals who were HIV negative and answered individual‐level stigma questions at enrolment to the cohort, there was no evidence of a statistically significant association between any domain of HIV stigma and risk of incident HIV infection. Among the full cohort of 26,110 individuals among whom HIV incidence was measured, there was no evidence that community‐level HIV incidence was associated with any domain of HIV stigma.

Conclusions

HIV stigma is often cited as a barrier to the effectiveness of HIV prevention programming. However, in the setting for the HPTN 071 “PopART trial,” measured stigma alone was not associated with the risk of HIV infection.

Ellen Nolte · Jemima H Kamano · Violet Naanyu · Anthony Etyang · Antonio Gasparrini · Kara Hanson · Hillary Koros · Richard Mugo · Adrianna Murphy · Robinson Oyando · TRIANTAFYLLOS PLIAKAS · Vincent Were · Ruth Willis · Edwina Barasa · Pablo Perel

BMJ Open, 2022, 12(3): e056261

Abstract

Introduction

Amid the rising number of people with non-communicable diseases (NCDs), Kenya has invested in strengthening primary care and in efforts to expand existing service delivery platforms to integrate NCD care. One such approach is the AMPATH (Academic Model Providing Access to Healthcare) model in western Kenya, which provides the platform for the Primary Health Integrated Care Project for Chronic Conditions (PIC4C), launched in 2018 to further strengthen primary care services for the prevention and control of hypertension, diabetes, breast and cervical cancer. This study seeks to understand how well PIC4C delivers on its intended aims and to inform and support scale up of the PIC4C model for integrated care for people with NCDs in Kenya.

Methods and analysis

The study is guided by a conceptual framework on implementing, sustaining and spreading innovation in health service delivery. We use a multimethod design combining qualitative and quantitative approaches, involving: (1) in-depth interviews with health workers and decision-makers to explore experiences of delivering PIC4C; (2) a cross-sectional survey of patients with diabetes or hypertension and in-depth interviews to understand how well PIC4C meets patients’ needs; (3) a cohort study with an interrupted time series analysis to evaluate the degree to which PIC4C leads to health benefits such as improved management of hypertension or diabetes; and (4) a cohort study of households to examine the extent to which the national hospital insurance chronic care package provides financial risk protection to people with hypertension or diabetes within PIC4C.

Ethics and dissemination

The study has received approvals from Moi University Institutional Research and Ethics Committee (FAN:0003586) and the London School of Hygiene & Tropical Medicine (17940). Workshops with key stakeholders at local, county, national and international levels will ensure early and wide dissemination of our findings to inform scale up of this model of care. We will also publish findings in peer-reviewed journals.

Anne Stangl · TRIANTAFYLLOS PLIAKAS · Jose Antonio Izazola-Licea · George Ayala · Tara S Beattie · Laura Ferguson · Luisa Orza · Sanyukta Mathur · Julie Pulerwitz · Alexandrina Iovita · Victoria Bendaud

PLoS One, 2022,17(2):e0264249

Abstract

Societal and legal impediments inhibit quality HIV prevention, care, treatment and support services and need to be removed. The political declaration adopted by UN member countries at the high-level meeting on HIV and AIDS in June 2021, included new societal enabler global targets for achievement by 2025 that will address this gap. Our paper describes how and why UNAIDS arrived at the societal enabler targets adopted. We conducted a scoping review and led a participatory process between January 2019 and June 2020 to develop an evidence-based framework for action, propose global societal enabler targets, and identify indicators for monitoring progress. A re-envisioned framework called the ‘3 S’s of the HIV response: Society, Systems and Services’ was defined. In the framework, societal enablers enhance the effectiveness of HIV programmes by removing impediments to service availability, access and uptake at the societal level, while service and system enablers improve efficiencies in and expand the reach of HIV services and systems. Investments in societal enabling approaches that remove legal barriers, shift harmful social and gender norms, reduce inequalities and improve institutional and community structures are needed to progressively realize four overarching societal enablers, the first three of which fall within the purview of the HIV sector: (i) societies with supportive legal environments and access to justice, (ii) gender equal societies, (iii) societies free from stigma and discrimination, and (iv) co-action across development sectors to reduce exclusion and poverty. Three top-line and 15 detailed targets were recommended for monitoring progress towards their achievement. The clear articulation of societal enablers in the re-envisioned framework should have a substantial impact on improving the effectiveness of core HIV programmes if implemented. Together with the new global targets, the framework will also galvanize advocacy to scale up societal enabling approaches with proven impact on HIV outcomes.

Gabriela B Gomez · MARIANA SIAPKA · Francesca Conradie · Norbert Ndjeka · Anna MC Celina Garfin · Nino Lomtadze · Zaza Avaliani · Nana Kiria · Shelly Malhotra · Sarah Cook-Scalise · Sandeep Juneja · Daniel Everitt · Melvin Spigelman · Anna Vassall

BMJ Open, 2021, 11(12): e051521

Abstract

Objectives

Patients with highly resistant tuberculosis have few treatment options. Bedaquiline, pretomanid and linezolid regimen (BPaL) is a new regimen shown to have favourable outcomes after six months. We present an economic evaluation of introducing BPaL against the extensively drug-resistant tuberculosis (XDR-TB) standard of care in three epidemiological settings.

Design

Cost-effectiveness analysis using Markov cohort model.

Setting

South Africa, Georgia and the Philippines.

Participants

XDR-TB and multidrug-resistant tuberculosis (MDR-TB) failure and treatment intolerant patients.

Interventions

BPaL regimen. PRIMARY AND SECONDARY OUTCOME MEASURES: (1) Incremental cost per disability-adjusted life years averted by using BPaL against standard of care at the Global Drug Facility list price. (2) The potential maximum price at which the BPaL regimen could become cost neutral.

Results

BPaL for XDR-TB is likely to be cost saving in all study settings when pretomanid is priced at the Global Drug Facility list price. The magnitude of these savings depends on the prevalence of XDR-TB in the country and can amount, over 5 years, to approximately US$ 3 million in South Africa, US$ 200 000 and US$ 60 000 in Georgia and the Philippines, respectively. In South Africa, related future costs of antiretroviral treatment (ART) due to survival of more patients following treatment with BPaL reduced the magnitude of expected savings to approximately US$ 1 million. Overall, when BPaL is introduced to a wider population, including MDR-TB treatment failure and treatment intolerant, we observe increased savings and clinical benefits. The potential threshold price at which the probability of the introduction of BPaL becoming cost neutral begins to increase is higher in Georgia and the Philippines (US$ 3650 and US$ 3800, respectively) compared with South Africa (US$ 500) including ART costs.

Conclusions

Our results estimate that BPaL can be a cost-saving addition to the local TB programmes in varied programmatic settings.

Lario Viljoen · Tila Mainga · Rozanne Casper · Constance Mubekapi-Musadaidzwa · Dillon T Wademan · Virginia A Bond · TRIANTAFYLLOS PLIAKAS · Chiti Bwalya · Anne Stangl · Mwelwa Phiri · Blia Yang · Kwame Shanaube · Peter Bock · Sarah Fidler · Richard Hayes · Helen Ayles · James R Hargreaves · Graeme Hoddinott · HPTN 071 (PopART) study team

Health Policy and Planning, 2021, 36(7): 1236

Abstract

The global expansion of HIV testing, prevention and treatment services is necessary to achieve HIV epidemic control and promote individual and population health benefits for people living with HIV (PLHIV) in sub-Saharan Africa. Community-based health workers (CHWs) could play a key role in supporting implementation at scale. In the HPTN 071 (PopART) trial in Zambia and South Africa, a cadre of 737 study-specific CHWs, working closely with government-employed CHW, were deployed to deliver a ‘universal’ door-to-door HIV prevention package, including an annual offer of HIV testing and referral services for all households in 14 study communities. We conducted a process evaluation using qualitative and quantitative data collected during the trial (2013-2018) to document the implementation of the CHW intervention in practice. We focused on the recruitment, retention, training and support of CHWs, as they delivered study-specific services. We then used these descriptions to: (i) analyse the fidelity to design of the delivery of the intervention package, and (ii) suggest key insights for the transferability of the intervention to other settings. The data included baseline quantitative data collected with the study-specific CHWs (2014-2018); and qualitative data from key informant interviews with study management (n = 91), observations of CHW training events (n = 12) and annual observations of and group discussions (GD) with intervention staff (n = 68). We show that it was feasible for newly recruited CHWs to implement the PopART intervention with good fidelity, supporting the interpretation of the trial outcome findings. This was despite some challenges in managing service quality and CHW retention in the early years of the programme. We suggest that by prioritizing the adoption of key elements of the in-home HIV services delivery intervention model-including training, emotional support to workers, monitoring and appropriate remuneration for CHWs-these services could be successfully transferred to new settings.

Nicola Foster · Lucy Cunnama · Kerrigan McCarthy · Lebogang Ramma · MARIANA SIAPKA · Edina Sinanovic · Gavin Churchyard · Katherine Fielding · Alison D Grant · Susan Cleary

PLoS One, 2021, 16(5): e0251547

Abstract

Background

In South Africa, replacing smear microscopy with Xpert-MTB/RIF (Xpert) for tuberculosis diagnosis did not reduce mortality and was cost-neutral. The unchanged mortality has been attributed to suboptimal Xpert implementation. We developed a mathematical model to explore how complementary investments may improve cost-effectiveness of the tuberculosis diagnostic algorithm.

Methods

Complementary investments in the tuberculosis diagnostic pathway were compared to the status quo. Investment scenarios following an initial Xpert test included actions to reduce pre-treatment loss-to-follow-up; supporting same-day clinical diagnosis of tuberculosis after a negative result; and improving access to further tuberculosis diagnostic tests following a negative result. We estimated costs, deaths and disability-adjusted-life-years (DALYs) averted from provider and societal perspectives. Sensitivity analyses explored the mediating influence of behavioural, disease- and organisational characteristics on investment effectiveness.

Findings

Among a cohort of symptomatic patients tested for tuberculosis, with an estimated active tuberculosis prevalence of 13%, reducing pre-treatment loss-to-follow-up from ~20% to ~0% led to a 4% (uncertainty interval [UI] 3; 4%) reduction in mortality compared to the Xpert scenario. Improving access to further tuberculosis diagnostic tests from ~4% to 90% among those with an initial negative Xpert result reduced overall mortality by 28% (UI 27; 28) at $39.70/ DALY averted. Effectiveness of investment scenarios to improve access to further diagnostic tests was dependent on a high return rate for follow-up visits.

Interpretation

Investing in direct and indirect costs to support the TB diagnostic pathway is potentially highly cost-effective.

Cleanthe Spanaki · Nikolaos E Rodopaios · Alexandra Koulouri · TRIANTAFYLLOS PLIAKAS · Sousana K Papadopoulou · Eleni Vasara · Petros Skepastianos · Tatiana Serafeim · Iro Boura · Emmanouil Dermitzakis · Anthony Kafatos

Nutrients, 2021, 13(2):627

Abstract

Lifestyle choices significantly influence mental health in later life. In this study we investigated the effects of the Christian Orthodox Church (COC) fasting diet, which includes long-term regular abstinence from animal-based products for half the calendar year, on cognitive function and emotional wellbeing of healthy adults. Two groups of fasting and non-fasting individuals were evaluated regarding their cognitive performance and the presence of anxiety and depression using the Mini Mental Examination Scale, the Hamilton Anxiety Scale, and the Geriatric Depression Scale (GDS), respectively. Data on physical activity, smoking, and vitamin levels were collected and correlated with mental health scoring. Negative binomial regression was performed to examine differences in the GDS scores between the two groups. Significantly lower levels of anxiety (7.48 ± 4.98 vs. 9.71 ± 5.25; p < 0.001) and depression (2.24 ± 1.77 vs. 3.5 ± 2.52; p < 0.001), along with better cognitive function (29.15 ± 0.79 vs. 28.64 ± 1.27; p < 0.001), were noticed in fasting compared to non-fasting individuals. GDS score was 31% lower (Incidence Rate Ratio: 0.69, 95% Confidence Interval: 0.56–0.85) in the fasting group compared to the control, while vitamin and ferrum levels did not differ. The COC fasting diet was found to have an independent positive impact on cognition and mood in middle-aged and elderly individuals.

Lario Viljoen · Virginia A Bond · Lindsey J Reynolds · Constance Mubekapi-Musadaidzwa · Dzunisani Baloyi · Rhoda Ndubani · Anne Stangl · Janet Seeley · TRIANTAFYLLOS PLIAKAS · Peter Bock · Sarah Fidler · Richard Hayes · Helen Ayles · James R Hargreaves · Graeme Hoddinott · HPTN 071 (PopART) study team

Sociology of health & illness, 2021, 43(1):167-185

Abstract

Despite continued development of effective HIV treatment, expanded access to care and advances in prevention modalities, HIV-related stigma persists. We examine how, in the context of a universal HIV-testing and treatment trial in South Africa and Zambia, increased availability of HIV services influenced conceptualisations of HIV. Using qualitative data, we explore people’s stigma-related experiences of living in ‘intervention’ and ‘control’ study communities. We conducted exploratory data analysis from a qualitative cohort of 150 households in 13 study communities, collected between 2016 and 2018. We found that increased availability of HIV-testing services influenced conceptualisations of HIV as normative (non-exceptional) and the visibility of people living with HIV (PLHIV) in household and community spaces impacted opportunities for stigma. There was a shift in community narratives towards individual responsibility to take up (assumingly) widely available service – for PLHIV to take care of their own health and to prevent onward transmission. Based on empirical data, we show that, despite a growing acceptance of HIV-related testing services, anticipated stigma persists through the mechanism of shifting responsibilisation. To mitigate the responsibilisation of PLHIV, heath implementers need to adapt anti-stigma messaging and especially focus on anticipated stigma.

Chris W Buck · Hanh Nguyen · MARIANA SIAPKA · Lopa Basu · Jessica Greenberg Cowan · Maria I De Deus · Megan Gleason · Ferreira Ferreira · Carla Xavier · Benedita Jose · Criménia Muthemba · Beatriz Simione · Peter Kerndt

AIDS research and therapy, 2021, 18(1): 3

Abstract

Background

Pediatric tuberculosis (TB), human immunodeficiency virus (HIV), and TB-HIV co-infection are health problems with evidence-based diagnostic and treatment algorithms that can reduce morbidity and mortality. Implementation and operational barriers affect adherence to guidelines in many resource-constrained settings, negatively affecting patient outcomes. This study aimed to assess performance in the pediatric HIV and TB care cascades in Mozambique.

Methods

A retrospective analysis of routine PEPFAR site-level HIV and TB data from 2012 to 2016 was performed. Patients 0-14 years of age were included. Descriptive statistics were used to report trends in TB and HIV indicators. Linear regression was done to assess associations of site-level variables with performance in the pediatric TB and HIV care cascades using 2016 data.

Results

Routine HIV testing and cotrimoxazole initiation for co-infected children in the TB program were nearly optimal at 99% and 96% in 2016, respectively. Antiretroviral therapy (ART) initiation was lower at 87%, but steadily improved from 2012 to 2016. From the HIV program, TB screening at the last consultation rose steadily over the study period, reaching 82% in 2016. The percentage of newly enrolled children who received either TB treatment or isoniazid preventive treatment (IPT) also steadily improved in all provinces, but in 2016 was only at 42% nationally. Larger volume sites were significantly more likely to complete the pediatric HIV and TB care cascades in 2016 (p value range 0.05 to < 0.001).

Conclusions

Mozambique has made significant strides in improving the pediatric care cascades for children with TB and HIV, but there were missed opportunities for TB diagnosis and prevention, with IPT utilization being particularly problematic. Strengthened TB/HIV programming that continues to focus on pediatric ART scale-up while improving delivery of TB preventive therapy, either with IPT or newer rifapentine-based regimens for age-eligible children, is needed.

Nina Sommerland · Caroline Masquillier · Asta Rau · Michelle Engelbrecht · Gladys Kigozi · TRIANTAFYLLOS PLIAKAS · Andre Janse van Rensburg · Edwin Wouters

Social Science and Medicine, 2020, 266:113450

Abstract

Rationale

The HIV and TB co-epidemic has a severe impact on the South African healthcare workforce and health system. HIV- and TB- stigma directed from healthcare workers (HCWs) towards colleagues not only has a negative impact on the mental health and well-being of the HCWs, but has been identified as a barrier to their own health-seeking behaviour. It also increases the strain on the health system due to absenteeism.

Objective

This cluster-randomised trial tested an intervention to reduce HIV- and TB-stigma among HCWs. The intervention, based on the theory of Diffusion of Innovations consisted of training healthcare workers as change agents in a Social and Behavioural Change Communication workshop to help them change stigmatising attitudes in the workplace. This was supported by a social marketing campaign.

Methods

Eight hospitals in the Free State province were randomised into intervention and control group in a stratified study design. 652 respondents randomly drawn from the hospitals were surveyed on aspects of HIV and TB stigma once in 2016 and again in 2018. Since the study only used four hospitals per intervention arm, cluster-based summaries were compared when analysing the intervention effect, using the nonparametric Mann-Whitney test. To explore how the intervention worked, 24 qualitative focus groups were conducted following the intervention.

Results

The quantitative test did not show a significant intervention effect on stigma between intervention and control groups. Qualitative evidence reported new awareness and changed behaviour related to HIV- and TB-stigma among individual HCWs, but a combination of factors including strong social hierarchies in the workplace and the down-scaling of the original version of the intervention seemed to reduce the impact. Conclusion The findings did not indicate a significant intervention effect, but show the potential of using HCWs as change agents to reduce HIV and TB stigma in their local communities.

MARIANA SIAPKA · Anna Vassall · Lucy Cunnama · Carlos Pineda · Diego Cerecero · Sedona Sweeney · Sergio Bautista-Arredondo · Lori Bollinger · Drew Cameron · Carol Levin · Gabriela B Gomez

The International Journal of Tuberculosis and Lung Disease, 2020, 24(8): 802-810

Abstract

BACKGROUND

Despite a scarcity of tuberculosis (TB) cost data, a substantial body of evidence has been accumulating for drug-susceptible TB (DS-TB) treatment. In this study, we review unit costs for DS-TB treatment from a provider´s perspective. We also examine factors driving cost variations and extrapolate unit costs across low- and middle-income countries (LMICs).

METHODS

We searched published and grey literature for any empirically collected TB cost estimates. We selected a subgroup of estimates looking at DS-TB treatment. We extracted information on activities and inputs included. We standardised costs into an average per person-month, fitted a multi-level regression model and cross-validated country-level predictions. We then extrapolated estimates for facility-based, directly observed DS-TB treatment across countries.

RESULTS

We included 95 cost estimates from 28 studies across 17 countries. Costs predictions were sensitive to characteristics such as delivery mode, whether hospitalisation was included, and inputs accounted for, as well as gross domestic product per capita. Extrapolation results are presented with uncertainty intervals (UIs) for LMICs. Predicted median costs per 6 months of treatment were US$315.30 (95% CI US$222.60-US$417.20) for low-income, US$527.10 (95% CI US$395.70-US$743.70) for lower middle-income and US$896.40 (95% CI US$654.00-US$1214.40) for upper middle-income countries.

CONCLUSIONS

Our study provides country-level DS-TB treatment cost estimates suitable for priority setting. These estimates, while not standing as a substitute for local high-quality primary data, can inform global, regional and national exercises.

Sedona Sweeney · Anna Vassall · Lorna Guinness · MARIANA SIAPKA · Natsayi Chimbindi · Don Mudzengi · Gabriela B. Gomez

Pharmacoeconomics, 2020, 38: 619-631

Abstract

Background and Objective

In context of the End TB goal of zero tuberculosis (TB)-affected households encountering catastrophic costs due to TB by 2020, the estimation of national prevalence of catastrophic costs due to TB is a priority to inform programme design. We explore approaches to estimate the national prevalence of catastrophic costs due to TB from existing datasets as an alternative to nationally representative surveys.

Methods

We obtained, standardized and merged three patient-level datasets from existing studies on patient-incurred costs due to TB in South Africa. A deterministic cohort model was developed with the aim of estimating the national prevalence of catastrophic costs, using national data on the prevalence of TB and likelihood of loss to follow-up by income quintile and HIV status. Two approaches were tested to parameterize the model with existing cost data. First, a meta-analysis summarized study-level data by HIV status and income quintile. Second, a regression analysis of patient-level data also included employment status, education level and urbanicity. We summarized findings by type of cost and examined uncertainty around resulting estimates.

Results

Overall, the median prevalence of catastrophic costs for the meta-analysis and regression approaches were 11% (interquartile range [IQR] 9–13%) and 6% (IQR 5–8%), respectively. Both approaches indicated that the main burden of catastrophic costs falls on the poorest households. An individual-level regression analysis produced lower uncertainty around estimates than a study-level meta-analysis.

Conclusions

This paper presents a novel application of existing data to estimate the national prevalence of catastrophic costs due to TB. This type of model could be useful for researchers and policy makers looking to inform certain policy decisions; however, some uncertainties remain due to limitations in data availability. There is an urgent need for standardized reporting of cost data and improved guidance on methods to collect income data to improve these estimates going forward.

Lucy Cunnama · Gabriela B. Gomez · MARIANA SIAPKA · Ben Herzel · Jeremy Hill · Angela Kairu · Carol Levin · Dickson Okello · Willyanne DeCormier Plosky · Inés Garcia Baena · Sedona Sweeney · Anna Vassall · Edina Sinanovic

Pharmacoeconomics, 2020, 38: 819-837

Abstract

Background

There is a need for easily accessible tuberculosis unit cost data, as well as an understanding of the variability of methods used and reporting standards of that data.

Objective

The aim of this systematic review was to descriptively review papers reporting tuberculosis unit costs from a healthcare provider perspective looking at methodological variation; to assess quality using a study quality rating system and machine learning to investigate the indicators of reporting quality; and to identify the data gaps to inform standardised tuberculosis unit cost collection and consistent principles for reporting going forward.

Methods

We searched grey and published literature in five sources and eight databases, respectively, using search terms linked to cost, tuberculosis and tuberculosis health services including tuberculosis treatment and prevention. For inclusion, the papers needed to contain empirical unit cost estimates for tuberculosis interventions from low- and middle-income countries, with reference years between 1990 and 2018. A total of 21,691 papers were found and screened in a phased manner. Data were extracted from the eligible papers into a detailed Microsoft Excel tool, extensively cleaned and analysed with R software (R Project, Vienna, Austria) using the user interface of RStudio. A study quality rating was applied to the reviewed papers based on the inclusion or omission of a selection of variables and their relative importance. Following this, machine learning using a recursive partitioning method was utilised to construct a classification tree to assess the reporting quality.

Results

This systematic review included 103 provider perspective papers with 627 unit costs (costs not presented here) for tuberculosis interventions among a total of 140 variables. The interventions covered were active, passive and intensified case finding; tuberculosis treatment; above-service costs; and tuberculosis prevention. Passive case finding is the detection of tuberculosis cases where individuals self-identify at health facilities; active case finding is detection of cases of those not in health facilities, such as through outreach; and intensified case finding is detection of cases in high-risk populations. There was heterogeneity in some of the reported methods used such cost allocation, amortisation and the use of top-down, bottom-up or mixed approaches to the costing. Uncertainty checking through sensitivity analysis was only reported on by half of the papers (54%), while purposive and convenience sampling was reported by 72% of papers. Machine learning indicated that reporting on ‘Intervention’ (in particular), ‘Urbanicity’ and ‘Site Sampling’, were the most likely indicators of quality of reporting. The largest data gap identified was for tuberculosis vaccination cost data, the Bacillus Calmette–Guérin (BCG) vaccine in particular. There is a gap in available unit costs for 12 of 30 high tuberculosis burden countries, as well as for the interventions of above-service costs, tuberculosis prevention, and active and intensified case finding.

Conclusion

Variability in the methods and reporting used makes comparison difficult and makes it hard for decision makers to know which unit costs they can trust. The study quality rating system used in this review as well as the classification tree enable focus on specific reporting aspects that should improve variability and increase confidence in unit costs. Researchers should endeavour to be explicit and transparent in how they cost interventions following the principles as laid out in the Global Health Cost Consortium’s Reference Case for Estimating the Costs of Global Health Services and Interventions, which in turn will lead to repeatability, comparability and enhanced learning from others.

James R Hargreaves · TRIANTAFYLLOS PLIAKAS · Graeme Hoddinott · Tila Mainga · Constance Mubekapi-Musadaidzwa · Deborah Donnell · Estelle Piwowar-Manning · Yaw Agyei · Nomtha F Bell-Mandla · Rory Dunbar · David Macleod · Sian Floyd · Peter Bock · Sarah Fidler · Richard Hayes · Janet Seeley · Anne Stangl · Virginia Bond · Helen Ayles · HPTN 071 (PopART) study team

Journal of Acquired Immune Deficiency Syndromes, 2020, 85(5): 561-570

Abstract

Background

The impact of HIV stigma on viral suppression among people living with HIV (PLHIV) is not well characterized.

Setting

Twenty-one communities in Zambia and South Africa, nested within the HPTN 071 (PopART) trial.

Methods

We analyzed data on viral suppression (<400 copies HIV RNA/mL) among 5662 laboratory-confirmed PLHIV aged 18-44 years who were randomly sampled within the PopART trial population cohort 24 months after enrolment (PC24). We collected data on experiences and internalization of stigma from those PLHIV who self-reported their HIV status (n = 3963/5662) and data on perceptions of stigma from a 20% random sample of all PLHIV (n = 1154/5662). We also measured stigma at the community-level among PLHIV, community members, and health workers. We analyzed the association between individual- and community-level measures of HIV stigma and viral suppression among PLHIV, adjusting for confounding.

Results

Of all 5662 PLHIV, 69.1% were virally suppressed at PC24. Viral suppression was highest among those 3963 cohort participants who self-reported living with HIV and were on ART (88.3%), and lower among those not on treatment (37.5%). Self-identifying PLHIV who reported internalized stigma were less likely to be virally suppressed (75.0%) than those who did not (80.7%; adjusted risk ratio, 0.94 95% CI: 0.89 to 0.98). Experiences, perceptions, and community-level measures of stigma were not associated with viral suppression.

Conclusion

Internalized stigma among PLHIV was associated with a lower level of viral suppression; other dimensions of stigma were not. Stigma reduction approaches that address internalized stigma should be an integral component of efforts to control the HIV epidemic.

Anne L Stangl · TRIANTAFYLLOS PLIAKAS · Tila Mainga · Mara Steinhaus · Constance Mubekapi-Musadaidzwa · Lario Viljoen · Rory Dunbar · Ab Schaap · Sian Floyd · Nomtha F Bell-Mandla · Virginia Bond · Graeme Hoddinott · Sarah Fidler · Richard Hayes · Helen Ayles · Peter Bock · Deborah Donnell · James R Hargreaves · HPTN 071 (PopART) study team

AIDS, 2020, 34(14): 2125-2135

Abstract

Objectives

To assess the impact of a combination HIV prevention intervention including universal testing and treatment (UTT) on HIV stigma among people living with HIV, and among community members and health workers not living with HIV.

Design

This HIV stigma study was nested in the HPTN 071 (PopART) trial, a three-arm cluster randomised trial conducted between 2013 and 2018 in 21 urban/peri-urban communities (12 in Zambia and nine in South Africa).

Methods

Using an adjusted two-stage cluster-level analysis, controlling for baseline imbalances, we compared multiple domains of stigma between the trial arms at 36 months. Different domains of stigma were measured among three cohorts recruited across all study communities: 4178 randomly sampled adults aged 18-44 who were living with HIV, and 3487 randomly sampled adults and 1224 health workers who did not self-report living with HIV.

Results

Prevalence of any stigma reported by people living with HIV at 36 months was 20.2% in arm A, 26.1% in arm B, and 19.1% in arm C (adjusted prevalence ratio, A vs. C 1.01 95% CI 0.49-2.08, B vs. C 1.34 95% CI 0.65-2.75). There were no significant differences between arms in any other measures of stigma across all three cohorts. All measures of stigma reduced over time (0.2–4.1% reduction between rounds) with most reductions statistically significant.

Conclusion

We found little evidence that UTT either increased or decreased HIV stigma measured among people living with HIV, or among community members or health workers not living with HIV. Stigma reduced over time, but slowly.

Harriet S Jones · Sian Floyd · Anne Stangl · Virginia Bond · Graeme Hoddinott · TRIANTAFYLLOS PLIAKAS · Justin Bwalya · Nomtha Mandla · Ayana Moore · Deborah Donnell · Peter Bock · Sarah Fidler · Richard Hayes · Helen Ayles · James R Hargreaves · HPTN 071 (PopART) study team

Tropical Medicine & International Health, 2020, 25(10): 1246-1260

Abstract

Objectives

Adherence to antiretroviral therapy (ART) leads to viral suppression for people living with HIV (PLHIV) and is critical for both individual health and reducing onward HIV transmission. HIV stigma is a risk factor that can undermine adherence. We explored the association between HIV stigma and self-reported ART adherence among PLHIV in 21 communities in the HPTN 071 (PopART) trial in Zambia and the Western Cape of South Africa.

Methods

We conducted a cross-sectional analysis of baseline data collected between 2013 and 2015, before the roll-out of trial interventions. Questionnaires were conducted, and consenting participants provided a blood sample for HIV testing. Poor adherence was defined as self-report of not currently taking ART, missing pills over the previous 7 days or stopping treatment in the previous 12 months. Stigma was categorised into three domains: community, health setting and internalised stigma. Multivariable logistic regression was used for analysis.

Results

Among 2020 PLHIV self-reporting ever taking ART, 1888 (93%) were included in multivariable analysis. Poor ART adherence was reported by 15.8% (n = 320) of participants, and 25.7% (n = 519) reported experiencing community stigma, 21.5% (n = 434) internalised stigma, and 5.7% (n = 152) health setting stigma. PLHIV who self-reported previous experiences of community and internalised stigma more commonly reported poor ART adherence than those who did not (aOR 1.63, 95% CI 1.21 -2.19, P = 0.001 and aOR 1.31, 95% CI 0.96-1.79, P = 0.09).

Conclusions

HIV stigma was associated with poor ART adherence. Roll-out of universal treatment will see an increasingly high proportion of PLHIV initiated on ART. Addressing HIV stigma could make an important contribution to supporting lifelong ART adherence.

Shari Krishnaratne · Virginia Bond · Anne Stangl · TRIANTAFYLLOS PLIAKAS · Hlengani Mathema · Pamela Lilleston · Graeme Hoddinott · Peter Bock · Helen Ayles · Sarah Fidler · James R. Hargreaves

AIDS Patient Care & STDS, 2020, 34(1): 38-50

Abstract

Stigma and judgment by health workers toward people living with HIV (PLHIV) and key populations can undermine the uptake of HIV services. In 2014, we recruited health workers delivering HIV services from 21 urban communities in South Africa and Zambia participating in the first year of the HPTN 071 (PopART) cluster-randomized trial. We analyzed self-reported levels of stigma and judgment toward (1) PLHIV, (2) women who sell sex, (3) men who have sex with men (MSM), and (4) young women who become pregnant before marriage. Using logistic regression, we compared responses between three health worker cadres and explored risk factors for stigmatizing attitudes. Highest levels of stigma and judgment were in relation to women who sell sex and MSM, especially in Zambia. Heath workers did not generally think that clients should be denied services, although this was reported slightly more commonly by community health workers. Higher education levels were associated with lower judgmental beliefs, whereas higher perceptions of coworker stigmatizing behaviors toward PLHIV and each key population were associated with holding judgmental beliefs. Training experience was not associated with judgmental attitudes for any of the key populations. Our findings confirm a high prevalence of judgmental attitudes toward key population groups but lower levels in relation to PLHIV, among all cadres of health workers in both countries. Planning and implementing targeted stigma reduction interventions within health settings are critical to meet the needs of vulnerable populations that face more stigmatizing attitudes from health workers.

Willyanne DeCormier Plosky · Lori A. Bollinger · Lily Alexander · Drew B. Cameron · Lauren N. Carroll · Lucy Cunnama · Gabriela B. Gomez · Carol Levin · Elliot Marseille · Mohamed Mustafa Diab · MARIANA SIAPKA · Edina Sinanovic · Anna Vassall · James G. Kahn

African Journal of AIDS Research, 2019, 18(4): 263-175

Abstract

Consistently defined, accurate, and easily accessible cost data are a valuable resource to inform efficiency analyses, budget preparation, and sustainability planning in global health. The Global Health Cost Consortium (GHCC) designed the Unit Cost Study Repository (UCSR) to be a resource for standardised HIV and TB intervention cost data displayed by key characteristics such as intervention type, country, and target population. To develop the UCSR, the GHCC defined a typology of interventions for each disease; aligned interventions according to the standardised principles, methods, and cost and activity categories from the GHCC Reference Case for Estimating the Costs of Global Health Services and Interventions; completed a systematic literature review; conducted extensive data extraction; performed quality assurance; grappled with complex methodological issues such as the proper approach to the inflation and conversion of costs; developed and implemented a study quality rating system; and designed a web-based user interface that flexibly displays large amounts of data in a user-friendly way. Key lessons learned from the extraction process include the importance of assessing the multiple uses of extracted data; the critical role of standardising definitions (particularly units of measurement); using appropriate classifications of interventions and components of costs; the efficiency derived from programming data checks; and the necessity of extraction quality monitoring by senior analysts. For the web interface, lessons were: understanding the target audiences, including consulting them regarding critical characteristics; designing the display of data in “levels”; and incorporating alert and unique trait descriptions to further clarify differences in the data.

Anne Stangl · Pamela Lilleston · Hlengani Mathema · TRIANTAFYLLOS PLIAKAS · Shari Krishnaratne · Kirsty Sievwright · Nomhle Bell-Mandla · Redwaan Vermaak · Tila Mainga · Mara Steinhaus ·Deborah Donnell · Ab Schaap · Peter Bock · Helen Ayles · Richard Hayes · Graeme Hoddinott · Virginia Bond · James R. Hargreaves

Journal of the International AIDS Society, 2019, 22(12): e25421

Abstract

Introduction

Integrating standardized measures of HIV stigma and discrimination into research studies of emerging HIV prevention approaches could enhance uptake and retention of these approaches, and care and treatment for people living with HIV (PLHIV), by informing stigma mitigation strategies. We sought to develop a succinct set of measures to capture key domains of stigma for use in research on HIV prevention technologies.

Methods

From 2013 to 2015, we collected baseline data on HIV stigma from three populations (PLHIV (N = 4053), community members (N = 5782) and health workers (N = 1560)) in 21 study communities in South Africa and Zambia participating in the HPTN 071 (PopART) cluster-randomized trial. Forty questions were adapted from a harmonized set of measures developed in a consultative, global process. Informed by theory and factor analysis, we developed seven scales, with values ranging from 0 to 3, based on a 4-point agreement Likert, and calculated means to assess different aspects of stigma. Higher means reflected more stigma. We developed two measures capturing percentages of PLHIV who reported experiencing any stigma in communities or healthcare settings in the past 12 months. We validated our measures by examining reliability using Cronbach’s alpha and comparing the distribution of responses across characteristics previously associated with HIV stigma.

Results

Thirty-five questions ultimately contributed to seven scales and two experience measures. All scales demonstrated acceptable to very good internal consistency. Among PLHIV, a scale captured internalized stigma, and experience measures demonstrated that 22.0% of PLHIV experienced stigma in the community and 7.1% in healthcare settings. Three scales for community members assessed fear and judgement, perceived stigma in the community and perceived stigma in healthcare settings. Similarly, health worker scales assessed fear and judgement, perceived stigma in the community and perceived co-worker stigma in healthcare settings. A higher proportion of community members and health workers reported perceived stigma than the proportion of PLHIV who reported experiences of stigma.

Conclusions

We developed novel, valid measures that allowed for triangulation of HIV stigma across three populations in a large-scale study. Such comparisons will illuminate how stigma influences and is influenced by programmatic changes to HIV service delivery over time.

Virginia Bond · Sinazo Nomsenge · Monde Mwamba · Daniel Ziba · Alice Birch · Constance Mubekapi-Musadaidzwa · Nosivuyile Vanqa · Lario Viljoen · TRIANTAFYLLOS PLIAKAS · Helen Ayles · James R. Hargreaves · Graeme Hoddinott · Anne Stangl · Janet Seeley

Health & Place, 2019, 55: 87-99

Abstract

Health workers in 21 government health facilities in Zambia and South Africa linked spatial organisation of HIV services and material items signifying HIV-status (for example, coloured client cards) to the risk of People Living with HIV (PLHIV) ‘being seen’ or identified by others. Demarcated HIV services, distinctive client flow and associated-items were considered especially distinguishing. Strategies to circumvent any resulting stigma mostly involved PLHIV avoiding and/or reducing contact with services and health workers reducing visibility of PLHIV through alterations to structures, items and systems. HIV spatial organisation and item adjustments, enacting PLHIV-friendly policies and wider stigma reduction initiatives could combined reduce risks of identification and enhance the privacy of health facility space and diminish stigma.

TRIANTAFYLLOS PLIAKAS · Karen Lock · Amanda Jones · Simon Aalders · Matt Egan

Journal of Public Health, 2019, 41(1): 110-118

Abstract

Background

‘Reducing the Strength’ (RtS) is a public health initiative encouraging retailers to voluntarily stop selling cheap, strong beers/ciders (≥6.5% alcohol by volume). This study evaluates the impact of RtS initiatives on alcohol availability and purchasing in three English counties with a combined population of 3.62 million people.

Methods

We used a multiple baseline time-series design to examine retail data over 29 months from a supermarket chain that experienced a two-wave, area-based role out of RtS: initially 54 stores (W1), then another 77 stores (W2). We measured impacts on units of alcohol sold (primary outcome: beers/ciders; secondary outcome: all alcoholic products), economic impacts on alcohol sales and substitution effects.

Results

We observed a non-significant W1 increase (+3.7%, 95% CI: −11.2, 21.0) and W2 decrease (−6.8%, 95% CI: −20.5, 9.4) in the primary outcome. We observed a significant W2 decrease in units sold across all alcohol products (−10.5%, 95% CI: −19.2, −0.9). The direction of effect between waves was inconsistent for all outcomes, including alcohol sales, with no evidence of substitution effects.

Conclusions

In the UK, voluntary RtS initiatives appear to have little or no impact on reducing alcohol availability and purchase from the broader population of supermarket customers.

TRIANTAFYLLOS PLIAKAS · Matt Egan · Janice Gibbons · Charlotte Ashton · Jan Hart · Karen Lock

Preventive Medicine, 2018, 116: 87-93

Abstract

Excessive alcohol consumption leads to negative health and social impacts at individual and population levels. Interventions that aim to limit the density of alcohol retail premises (including cumulative impact policies (CIPs)) have been associated with decreases in alcohol-related crime and alcohol-related hospital admissions. We evaluated the quantitative impact of introducing a new alcohol licensing policy that included a comprehensive Cumulative Impact Policy (CIP) enforced in seven Cumulative Impact Zones (CIZs) in one English Local Authority in 2013. We used time series analysis to assess immediate and longer term impacts on licensing decisions and intermediate outcomes, including spatial and temporal alcohol availability, crime, alcohol-related ambulance call-outs and on-licence alcohol retail sales across the Local Authority and in CIZs and non-CIZs during the period 2008 to 2016. We found no impact on licence application rates but post-intervention applications involved fewer trading hours. Application approvals declined initially but not over the longer term. Longer term, small reductions in units of alcohol sold in bars (−2060, 95% confidence interval (CI) = −3033, −1087) were observed in areas with more intensive licensing policies (‘Cumulative Impact Zones’ (CIZs)). Significant initial declines in overall crime rates (CIZs = −12.2%, 95% CI = −18.0%, −6.1%; non-CIZs = −8.0%, 95% CI = −14.0%, −1.6%) were only partially reversed by small, longer term increases. Ambulance callout rates did not change significantly. The intervention was partially successful but a more intensive and sustained implementation may be necessary for longer term benefits.

Sophie Hawkesworth · Richard J Silverwood · Ben Armstrong · TRIANTAFYLLOS PLIAKAS · Kiran Nanchalal · Barbara J Jefferis · Claudio Sartini · Antoinette A Amuzu · S Goya Wannamethee · Sheena E Ramsay · Juan-Pablo Casas · Richard W Morris · Peter H Whincup · Karen Lock

Journal of Epidemiology and Community Health, 2018, 72(2): 121-131

Abstract

Background 

Policy initiatives such as WHO Age Friendly Cities recognise the importance of the urban environment for improving health of older people, who have both low physical activity (PA) levels and greater dependence on local neighbourhoods. Previous research in this age group is limited and rarely uses objective measures of either PA or the environment.

Methods 

We investigated the association between objectively measured PA (Actigraph GT3x accelerometers) and multiple dimensions of the built environment, using a cross-sectional multilevel linear regression analysis. Exposures were captured by a novel foot-based audit tool that recorded fine-detail neighbourhood features relevant to PA in older adults, and routine data.

Results 

795 men and 638 women aged 69–92 years from two national cohorts, covering 20 British towns, were included in the analysis. Median time in moderate to vigorous PA (MVPA) was 27.9 (lower quartile: 13.8, upper quartile: 50.4) minutes per day. There was little evidence of associations between any of the physical environmental domains (eg, road and path quality defined by latent class analysis; number of bus stops; area aesthetics; density of shops and services; amount of green space) and MVPA. However, analysis of area-level income deprivation suggests that the social environment may be associated with PA in this age group.

Conclusions 

Although small effect sizes cannot be discounted, this study suggests that older individuals are less affected by their local physical environment and more by social environmental factors, reflecting both the functional heterogeneity of this age group and the varying nature of their activity spaces.

Sophie Hawkesworth · Richard J Silverwood · Ben Armstrong · TRIANTAFYLLOS PLIAKAS · Kiran Nanchalal · Claudio Sartini · Antoinette A Amuzu · Goya Wannamethee · Janice Atkins · Sheena E Ramsay · Juan-Pablo Casas · Richard W Morris · Peter H Whincup · Karen Lock

International Journal of Behavioral Nutrition and Physical Activity, 2017, 14(1): 128

Abstract

Background

Local neighbourhood environments can influence dietary behavior. There is limited evidence focused on older people who are likely to have greater dependence on local areas and may suffer functional limitations that amplify any neighbourhood impact.

Methods

Using multi-level ordinal regression analysis we investigated the association between multiple dimensions of neighbourhood food environments (captured by fine-detail, foot-based environmental audits and secondary data) and self-reported frequency of fruit and vegetable intake. The study was a cross-sectional analysis nested within two nationally representative cohorts in the UK: the British Regional Heart Study and the British Women’s Heart and Health Study. Main exposures of interest were density of food retail outlets selling fruits and vegetables, the density of fast food outlets and a novel measure of diversity of the food retail environment.

Results

A total of 1124 men and 883 women, aged 69 – 92 years, living in 20 British towns were included in the analysis. There was strong evidence of an association between area income deprivation and fruit and vegetable consumption, with study members in the most deprived areas estimated to have 27% (95% CI: 7, 42) lower odds of being in a higher fruit and vegetable consumption category relative to those in the least deprived areas. We found no consistent evidence for an association between fruit and vegetable consumption and a range of other food environment domains, including density of shops selling fruits and vegetables, density of premises selling fast food, the area food retail diversity, area walkability, transport accessibility, or the local food marketing environment. For example, individuals living in areas with greatest fruit and vegetable outlet density had 2% (95% CI: -22, 21) lower odds of being in a higher fruit and vegetable consumption category relative to those in areas with no shops.

Conclusions

Although small effect sizes in environment-diet relationships cannot be discounted, this study suggests that older people are less influenced by physical characteristics of neighbourhood food environments than is suggested in the literature. The association between area income deprivation and diet may be capturing an important social aspect of neighbourhoods that influence food intake in older adults and warrants further research.

Ruth Ponsford · Jennifer Ford · Helena Korjonen · Emma Hughes · Asha Keswani · TRIANTAFYLLOS PLIAKAS · Matt Egan

Implementation Science, 2017, 12(1): 91

Abstract

Background

Improving mechanisms for knowledge translation (KT) and connecting decision-makers to each other and the information and evidence they consider relevant to their work remains a priority for public health. Virtual communities of practices (CoPs) potentially offer an affordable and flexible means of encouraging connection and sharing of evidence, information and learning among the public health community in ways that transgress traditional geographical, professional, institutional and time boundaries. The suitability of online CoPs in public health, however, has rarely been tested. This paper explores the reasons why particular online CoP for alcohol harm reduction hosted by the UK Health Forum failed to generate sufficient interest from the group of public health professionals at which it was aimed.

Methods

The study utilises online web-metrics demonstrating a lack of online activity on the CoP. One hundred and twenty seven responses to an online questionnaire were used to explore whether the lack of activity could be explained by the target audience’s existing information and evidence practices and needs. Qualitative interviews with 10 members describe in more detail the factors that shape and inhibit use of the virtual CoP by those at which it was targeted.

Results

Quantitative and qualitative data confirm that the target audience had an interest in the kind of information and evidence the CoP was set up to share and generate discussion about, but also that participants considered themselves to already have relatively good access to the information and evidence they needed to inform their work. Qualitative data revealed that the main barriers to using the CoP were a proliferation of information sources meaning that participants preferred to utilise trusted sources that were already established within their daily routines and a lack of time to engage with new online tools that required any significant commitment.

Conclusions

Specialist online CoPs are competing for space in an already crowded market. A target audience that regards itself as busy and over-supplied is unlikely to commit to a new service without the assurance that the service will provide unique and valuable well-summarised information, which would reduce the need to spend time accessing competing resources.

MARIANA SIAPKA · Carol Dayo Obure · Susannah H Mayhew · Sedona Sweeney · Justin Fenty · Integra Initiative · Anna Vassall

Health Policy and Planning, 2017, 32(suppl 4): iv82-iv90

Abstract

The lack of human resources is a key challenge in scaling up of HIV services in Africa’s health care system. Integrating HIV services could potentially increase their effectiveness and optimize the use of limited resources and clinical staff time. We examined the impact of integration of provider initiated HIV counselling and testing (PITC) and family planning (FP counselling and FP provision) services on duration of consultation to assess the impact of PITC and FP integration on staff workload. This study was conducted in 24 health facilities in Kenya under the Integra Initiative, a non-randomized, pre/post intervention trial to evaluate the impact of integrated HIV and sexual and reproductive health services on health and service outcomes. We compared the time spent providing PITC-only services, FP-only services and integrated PITC/FP services. We used log-linear regression to assess the impact of plausible determinants on the duration of clients’ consultation times. Median consultation duration times were highest for PITC-only services (30 min), followed by integrated services (10 min) and FP-only services (8 min). Times for PITC-only and FP-only services were 69.7% higher (95% Confidence Intervals (CIs) 35.8–112.0) and 43.9% lower (95% CIs −55.4 to − 29.6) than times spent on these services when delivered as an integrated service, respectively. The reduction in consultation times with integration suggests a potential reduction in workload. The higher consultation time for PITC-only could be because more pre- and post-counselling is provided at these stand-alone services. In integrated PITC/FP services, the duration of the visit fell below that required by HIV testing guidelines, and service mix between counselling and testing substantially changed. Integration of HIV with FP services may compromise the quality of services delivered and care must be taken to clearly specify and monitor appropriate consultation duration times and procedures during the process of integrating HIV and FP services.

Frank de Vocht · Kate Tilling · TRIANTAFYLLOS PLIAKAS · Colin Angus · Matt Egan · Alan Brennan · Rona Campbell · Matthew Hickman

Journal of Epidemiology and Community Health, 2017, 71(9): 912-918

Abstract

Background

Control of alcohol licensing at local government level is a key component of alcohol policy in England. There is, however, only weak evidence of any public health improvement. We used a novel natural experiment design to estimate the impact of new local alcohol licensing policies on hospital admissions and crime.

Methods

We used Home Office licensing data (2007-2012) to identify (1) interventions: local areas where both a cumulative impact zone and increased licensing enforcement were introduced in 2011; and (2) controls: local areas with neither. Outcomes were 2009-2015 alcohol-related hospital admissions, violent and sexual crimes, and antisocial behaviour. Bayesian structural time series were used to create postintervention synthetic time series (counterfactuals) based on weighted time series in control areas. Intervention effects were calculated from differences between measured and expected trends. Validation analyses were conducted using randomly selected controls.

Results

5 intervention and 86 control areas were identified. Intervention was associated with an average reduction in alcohol-related hospital admissions of 6.3% (95% credible intervals (CI) -12.8% to 0.2%) and to lesser extent with a reduced in violent crimes, especially up to 2013 (-4.6%, 95% CI -10.7% to 1.4%). There was weak evidence of an effect on sexual crimes up 2013 (-8.4%, 95% CI -21.4% to 4.6%) and insufficient evidence of an effect on antisocial behaviour as a result of a change in reporting.

Conclusion

Moderate reductions in alcohol-related hospital admissions and violent and sexual crimes were associated with introduction of local alcohol licensing policies. This novel methodology holds promise for use in other natural experiments in public health.

Anna Vassall · MARIANA SIAPKA · Nicola Foster · Lucy Cunnama · Lebogang Ramma · Katherine Fielding · Kerrigan McCarthy · Gavin Churchyard · Alison Grant · Edina Sinanovic

Lancet Global Health, 2017, 5: e710-19

Abstract

Background

In 2010 a new diagnostic test for tuberculosis, Xpert MTB/RIF, received a conditional programmatic recommendation from WHO. Several model-based economic evaluations predicted that Xpert would be cost-effective across sub-Saharan Africa. We investigated the cost-effectiveness of Xpert in the real world during national roll-out in South Africa.

Methods

For this real-world cost analysis and economic evaluation, we applied extensive primary cost and patient event data from the XTEND study, a pragmatic trial examining Xpert introduction for people investigated for tuberculosis in 40 primary health facilities (20 clusters) in South Africa enrolled between June 8, and Nov 16, 2012, to estimate the costs and cost per disability-adjusted life-year averted of introducing Xpert as the initial diagnostic test for tuberculosis, compared with sputum smear microscopy (the standard of care).

Findings

The mean total cost per study participant for tuberculosis investigation and treatment was US$312·58 (95% CI 252·46–372·70) in the Xpert group and $298·58 (246·35–350·82) in the microscopy group. The mean health service (provider) cost per study participant was $168·79 (149·16–188·42) for the Xpert group and $160·46 (143·24–177·68) for the microscopy group of the study. Considering uncertainty in both cost and effect using a wide range of willingness to pay thresholds, we found less than 3% probability that Xpert introduction improved the cost-effectiveness of tuberculosis diagnostics.

Interpretation

After analysing extensive primary data collection during roll-out, we found that Xpert introduction in South Africa was cost-neutral, but found no evidence that Xpert improved the cost-effectiveness of tuberculosis diagnosis. Our study highlights the importance of considering implementation constraints, when predicting and evaluating the cost-effectiveness of new tuberculosis diagnostics in South Africa.

TRIANTAFYLLOS PLIAKAS · Sophie Hawkesworth · Richard J Silverwood · Kiran Nanchalal · Chris Grundy · Ben Armstrong · Juan-Pablo Casas · Richard W Morris · Paul Wilkinson · Karen Lock

Health Place, 2017, 43: 75-84

Abstract

The role of the neighbourhood environment in influencing health behaviours continues to be an important topic in public health research and policy. Foot-based street audits, virtual street audits and secondary data sources are widespread data collection methods used to objectively measure the built environment in environment-health association studies. We compared these three methods using data collected in a nationally representative epidemiological study in 17 British towns to inform future development of research tools. There was good agreement between foot-based and virtual audit tools. Foot based audits were superior for fine detail features. Secondary data sources measured very different aspects of the local environment that could be used to derive a range of environmental measures if validated properly. Future built environment research should design studies a priori using multiple approaches and varied data sources in order to best capture features that operate on different health behaviours at varying spatial scales.

Michelle Remme · MARIANA SIAPKA · Olivier Sterck · Mthuli Ncube · Charlotte Watts · Anna Vassall

Social Science Medicine, 2016, 169: 66-76

Abstract

Despite optimism about the end of AIDS, the HIV response requires sustained financing into the future. Given flat-lining international aid, countries’ willingness and ability to shoulder this responsibility will be central to access to HIV care. This paper examines the potential to expand public HIV financing, and the extent to which governments have been utilising these options. We develop and compare a normative and empirical approach. First, with data from the 14 most HIV-affected countries in sub-Saharan Africa, we estimate the potential increase in public HIV financing from economic growth, increased general revenue generation, greater health and HIV prioritisation, as well as from more unconventional and innovative sources, including borrowing, health-earmarked resources, efficiency gains, and complementary non-HIV investments. We then adopt a novel empirical approach to explore which options are most likely to translate into tangible public financing, based on cross-sectional econometric analyses of 92 low and middle-income country governments’ most recent HIV expenditure between 2008 and 2012. If all fiscal sources were simultaneously leveraged in the next five years, public HIV spending in these 14 countries could increase from US$3.04 to US$10.84 billion per year. This could cover resource requirements in South Africa, Botswana, Namibia, Kenya, Nigeria, Ethiopia, and Swaziland, but not even half the requirements in the remaining countries. Our empirical results suggest that, in reality, even less fiscal space could be created (a reduction by over half) and only from more conventional sources. International financing may also crowd in public financing. Most HIV-affected lower-income countries in sub-Saharan Africa will not be able to generate sufficient public resources for HIV in the medium-term, even if they take very bold measures. Considerable international financing will be required for years to come. HIV funders will need to engage with broader health and development financing to improve government revenue-raising and efficiencies.

Sarah Milton · TRIANTAFYLLOS PLIAKAS · Sophie Hawkesworth · Kiran Nanchalal · Chris Grundy · Antoinette Amuzu · Juan-Pablo Casas · Karen Lock

Health Place, 2015, 36: 127-33

Abstract

A growing body of literature explores the relationship between the built environment and health, and the methodological challenges of understanding these complex interactions across the lifecourse. The impact of the neighbourhood environment on health and behaviour amongst older adults has received less attention, despite this age group being potentially more vulnerable to barriers in their surrounding social and physical environment. A qualitative geographical information systems (QGIS) approach was taken to facilitate the understanding of how older people over 70 in 5 UK towns interact with their local neighbourhood. The concept of neighbourhood changed seasonally and over the lifecourse, and was associated with social factors such as friends, family, or community activities, rather than places. Spaces stretched further than the local, which is problematic for older people who rely on variable public transport provision. QGIS techniques prompted rich discussions on interactions with and the meanings of ‘place’ in older people.

Aurélia Lépine · Neeti Nundy · Maggie Kilbourne-Brook · MARIANA SIAPKA · Fern Terris-Prestholt

PLoS One, 2015, 10(8): e0134510

Abstract

Background

Though South Africa has high contraceptive use, unintended pregnancies are still widespread. The SILCS diaphragm could reduce the number of women with unmet need by introducing a discreet, woman-initiated, non-hormonal barrier method to the contraceptive method mix.

Methods

A decision model was built to estimate the impact and cost-effectiveness of the introduction of the SILCS diaphragm in Gauteng among women with unmet need for contraception in terms of unintended and mistimed pregnancies averted, assuming that the available contraceptives on the market were not a satisfying option for those women. Full costs were estimated both from a provider’s and user’s perspective, which also accounts for women’s travel and opportunity cost of time, assuming a 5% uptake among women with unmet contraceptive need. The incremental cost-effectiveness ratio is computed at five and 10 years after introduction to allow for a distribution of fixed costs over time. A probabilistic sensitivity analysis was conducted to incorporate decision uncertainty.

Results

The introduction of the SILCS diaphragm in Gauteng could prevent an estimated 8,365 unintended pregnancies and 2,117 abortions over five years, at an annual estimated cost of US$55 per woman. This comes to a cost per pregnancy averted of US$153 and US$171 from a user’s and provider’s perspectives, respectively, with slightly lower unit costs at 10 years. Major cost drivers will be the price of the SILCS diaphragm and the contraceptive gel, given their large contribution to total costs (around 60%).

Conclusions

The introduction of the SILCS diaphragm in the public sector is likely to provide protection for some women for whom current contraceptive technologies are not an option. However to realize its potential, targeting will be needed to reach women with unmet need and those with likely high adherence. Further analyses are needed among potential users to optimize the introduction strategy.

TRIANTAFYLLOS PLIAKAS · Paul Wilkinson · Cathryn Tonne

Health Place, 2014, 27: 186-93

Abstract

Socioeconomic gradients in walking are well documented but the underlying reasons remain unclear. We examined the contribution of objective measures of the physical environment at residence to socioeconomic gradients in walking in 3363 participants (50-74years) from the Whitehall II study (2002-2004). Individual-level socioeconomic position was measured as most recent employment grade. The contribution of multiple measures of the physical environment to socioeconomic position gradients in self-reported log transformed minutes walking/week was examined by linear regression. Objective measures of the physical environment contributed only to a small extent to socioeconomic gradients in walking in middle-aged and older adults living in Greater London, UK. Of these, only the number of killed and seriously injured road traffic casualties per km of road was predictive of walking. More walking in areas with high rates of road traffic casualties per km of road may signal an effect not of injury risk but of more central locations with multiple destinations within short distances (‘compact neighbourhoods’). This has potential implications for urban planning to promote physical activity.

Michelle Remme · MARIANA SIAPKA · Anna Vassall · Lori Heise · Jantine Jacobi · Claudia Ahumada · Jill Gay · Charlotte Watts

Journal of the International AIDS Society, 2014, 17: 19228

Abstract

Introduction

Harmful gender norms and inequalities, including gender-based violence, are important structural barriers to effective HIV programming. We assess current evidence on what forms of gender-responsive intervention may enhance the effectiveness of basic HIV programmes and be cost-effective.

Methods

Effective intervention models were identified from an existing evidence review (“what works for women”). Based on this, we conducted a systematic review of published and grey literature on the costs and cost-effectiveness of each intervention identified. Where possible, we compared incremental costs and effects.

Results

Our effectiveness search identified 36 publications, reporting on the effectiveness of 22 HIV interventions with a gender focus. Of these, 11 types of interventions had a corresponding/comparable costing or cost-effectiveness study. The findings suggest that couple counselling for the prevention of vertical transmission; gender empowerment, community mobilization, and female condom promotion for female sex workers; expanded female condom distribution for the general population; and post-exposure HIV prophylaxis for rape survivors are cost-effective HIV interventions. Cash transfers for schoolgirls and school support for orphan girls may also be cost-effective in generalized epidemic settings.

Conclusions

There has been limited research to assess the cost-effectiveness of interventions that seek to address women’s needs and transform harmful gender norms. Our review identified several promising, cost-effective interventions that merit consideration as critical enablers in HIV investment approaches, as well as highlight that broader gender and development interventions can have positive HIV impacts. By no means an exhaustive package, these represent a first set of interventions to be included in the investment framework.

Michael Chourdakis · Vasileios Kontogiannis · Konstantinos Malachas · TRIANTAFYLLOS PLIAKAS · Aristidis Kritis

Journal of Community Health, 2014, 39(5): 972-9

Abstract

The purpose of this study was to examine self-care behaviors of adults with type 2 diabetes mellitus living in the Metropolitan Area of Thessaloniki in Northern Greece. The Summary of Diabetes Self-Care behaviors measurement was administered to 215 patients, out of which 177 were eligible to participate (87 males). Patients, aged 30 years or more, were recruited through a university hospital day-clinic. Older patients (>65 years), as well as those with “higher educational level” did not distribute their daily carbohydrate intake equally. Nevertheless, they were more likely to adapt to their physician’s recommendations regarding medication and to regularly perform suggested blood glucose checking. Exercise patterns were more often found for higher educated, earlier diagnosed males. Younger patients were less likely to follow their healthcare professional’s recommendations, regarding diet, medication intake, blood glucose checking, foot care and exercise compared to older patients. These results pose a higher risk for complications and morbidity in younger patients with type 2 diabetes mellitus, who most possibly will require intensive treatment in the future.

MARIANA SIAPKA · Michelle Remme · Carol D Obure · Claudia B Maier · Karl L Dehne · Anna Vassall

Bulletin of the World Health Organization, 2014, 92(7): 499-511AD

Abstract

Objective

To synthesize the data available–on costs, efficiency and economies of scale and scope–for the six basic programmes of the UNAIDS Strategic Investment Framework, to inform those planning the scale-up of human immunodeficiency virus (HIV) services in low- and middle-income countries.

Methods

The relevant peer-reviewed and “grey” literature from low- and middle-income countries was systematically reviewed. Search and analysis followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

Findings

Of the 82 empirical costing and efficiency studies identified, nine provided data on economies of scale. Scale explained much of the variation in the costs of several HIV services, particularly those of targeted HIV prevention for key populations and HIV testing and treatment. There is some evidence of economies of scope from integrating HIV counselling and testing services with several other services. Cost efficiency may also be improved by reducing input prices, task shifting and improving client adherence.

Conclusion

HIV programmes need to optimize the scale of service provision to achieve efficiency. Interventions that may enhance the potential for economies of scale include intensifying demand-creation activities, reducing the costs for service users, expanding existing programmes rather than creating new structures, and reducing attrition of existing service users. Models for integrated service delivery–which is, potentially, more efficient than the implementation of stand-alone services–should be investigated further. Further experimental evidence is required to understand how to best achieve efficiency gains in HIV programmes and assess the cost-effectiveness of each service-delivery model.

Anna Vassall · Michelle Remme · Charlotte Watts · Timothy Hallett · MARIANA SIAPKA · Peter Vickerman · Fern Terris-Prestholt · Markus Haacker · Lori Heise · Andy Haines · Rifat Atun · Peter Piot

PLoS Medicine, 2013, 10(12): e1001567

Summary points

• The financing needs of the HIV response will remain substantial for many years to come, with current commitments becoming increasingly out of line with future fiscal liabilities.
• A change in economic approach will be required, drawing on increased domestic funding, improvements in efficiency, and identification of innovative new funding streams.
• Organisations providing HIV services must critically examine and justify their costs and priorities, become increasingly involved in broader health systems strengthening, and find ways to simultaneously support good governance and wider development objectives.
• There is need for a renewed economic case to now be made for a reinvigorated response and a sustainable, long-term national and global financial commitment to ending AIDS.

TRIANTAFYLLOS PLIAKAS · David H McCarthy

Annals of Human Biology, 2010, 37(1): 10-22

Abstract

Background

Short leg length (LL) and childhood obesity have been independently associated with a higher risk for adult disease. However, the contribution of relative LL to overweight and obesity in children remains an under-researched area.

Aim

To utilize data from a large cross-sectional anthropometric survey to assess the association of LL to height ratio (LLHR, leg length/height) with measures of overweight and obesity in British children.

Methods

Children were analysed from the bottom and top body mass index (BMI) standard deviation score (SDS) quartiles (3825 children, boys=1686) or waist circumference (WC) SDS quartiles (3824 children, boys=1687). The top quartile was defined as the ‘high’ BMI or WC SDS group and the lower bottom quartile as the ‘low’ BMI or WC SDS group. Height and LL were expressed as SDSs using current references and LLHR was calculated.

Results

Children in the ‘high’ groups were taller with longer legs but had a lower LLHR across most ages. The magnitude of the difference was greater for BMI than WC in both genders.

Conclusion

Altered body dimensions appear to be linked to measures of overweight and obesity in children but longitudinal studies are needed to confirm this suggestion.